Patient Onboarding

Please complete the patient registration and consent form at least 48 hours prior to your appointment. This page may be printed and returned via email to info@mindgutclinic.com.au

Food & Symptom Diary

Clinic Contact

Contact Details

Given Name(s) *

Family Name: *

Gender

Pronouns

Date of Birth *Email Address*

Phone Number *Occupation *

Street Address*

Suburb*

Postcode*

Emergency Contact

Name *

Relationship *

Contact Number *

Medicare Details

Medicare Number *

Reference Number *

Valid To *

Usual GP Details

GP Name *

GP Address *

GP Phone Number *

GP Email

Referring Doctor (if not GP)

Referring Doctor Name

Referring Doctor Address

Referring Doctor Phone Number

Referring Doctor Email

Reason for Appointment *

Irritable Bowel Syndrome

Inflammatory Bowel Disease

Abdominal & Pelvic Pain

Functional Bloating

GORD

Functional Dyspepsia

Coeliac Disease

Aerophagia / Belching

Nausea & Vomiting

Faecal Incontinence

Disordered Eating

Other

When were you diagnosed?

Your symptoms

What are the main symptoms you experience? Tick any that are relevant *

Skin Problems

Mouth ulcers

Eczema

Psoriasis

Rashes

Behavioural

Fatigue/tiredness

Sleep disturbances

Foggy headaches

Poor concentration

Other

Medications

Please list any medications you currently take plus dosage (including vitamins and herbal preparations) *

Consent

We require your consent to collect personal information about you. Please read this information carefully and sign where indicated below.

The Mind + Gut Specialist Clinic collects information from you for the primary purpose of providing quality health care. We will use the information you provide in the following ways:

Administrative purposes in running our clinic
Billing purposes including Medicare and Health Insurance Commission requirements
Retrieving medical history from other health providers
Disclosure to others involved in your health care including doctors and specialists outside this clinic. If you do not wish for contact to be made with others involved in your health care, please tick here:

I have read the information above and understand the reasons why information must be collected. I am also aware that the clinic follows guidelines to protect patient privacy in compliance with privacy legislation.

I consent to the handling of my information by this practice for the purposes set out above.

I have read & agree to the Cancellation Policy

Your name (print) *

Date *

Optional

I do not want staff from the Mind + Gut Specialist Clinic to correspond with my GP

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

Book an appointment

We can help with disorders including irritable bowel syndrome, inflammatory bowel disease, coeliac disease, GORD and many others.

Our team of specialist gut-directed hypnotherapists, psychologists and dieticians are highly skilled and specific in their management approach.

We use evidence-based techniques that have been proven to improve long-term gastrointestinal symptoms. We see both adults and children. No referral is required to make an appointment with us.

Book Appointment

Patient Onboarding

Clinic Contact

Contact Details

Emergency Contact

Medicare Details

Usual GP Details

Referring Doctor (if not GP)

Reason for Appointment *

Your symptoms

Gastrointestinal symptoms

Skin Problems

Behavioural

Nutritional Deficiencies

Medications

Consent

Book an appointment